Lenore B. Behar, PhD, Director Child & Family Program Strategies Durham, North Carolina

1. Community Based Interventions In Two Parts: Systems Of Care AndApproaches To Recovery From Psychological Trauma Lenore B. Behar, PhD, Director Child & Family Program Strategies Durham, North Carolina

2. Presentation forMississippi Institute on School Health,Wellness and SafetyThe Super Conference September 27-29, 2006 Philadelphia, Mississippi

3. For Bibliography & Slides Go to: www.lenorebehar.com See: Presentations Community Based Interventions In Two Parts: Systems Of Care And Approaches To Recovery From Psychological Trauma Mississippi Super Conference,September 2006

4. Definitions Children: The term “children” includes all people eligible for System of Care services, as defined by the State.

5. Two Paths for Children Exposed to Trauma • System of Care as a Mode of Service Delivery for Children with Serious Emotional Problems • Trauma Focused Interventions, • usually Individual or Family Therapies

6. Converging Paths for Children Exposed to Trauma • Since 1985, System of Care has been federal policy for children with serious emotional disturbances, and their families • Since 1993, System of Care has been state policy in Mississippi

7. The Focus of System of Carein Mississippi To provide community based care and decrease the use of inappropriate out-of-home placements by using pooled resources from mental health, education, child welfare, and Medicaid for children with SED

8. How Mississippi SOC Evolved • legislatively mandated services—one of the first in the country • mechanisms to review service quality • policy guidance from the State • state and community level interagency teams for children who are difficult to serve—multi-agency assessment and planning teams (MAP) • teams include agencies and parents

9. Support from the Family Organization • Mississippi Families as Allies for Children's Mental Health (MSFAA) established in 1990 • one of the first family-run, family focused organizations in the country • provided ongoing support to System of Care development

10. System of Care Principles • Child centered, individualized • Family focused • Community based • Comprehensive • Culturally competent • Accountable/evidence based • Coordinated across agencies • Requires care management

11. Why Do We Need SOC? • Need collective expertise • Need unified approach to child and family • Need to use all the resources available to child and family

12. It Is Rocket Science!!

13. What is the Population for the System of Care? The definition is clear: • Children with serious/severe emotional disturbances and their families • Children and families who need the services of multiple agencies, or who need multiple services

14. What is SED? An emotional/behavioral disorder diagnosed by a qualified professional that: • Requires services of several agencies • Significantly impairs functioning • Is anticipated to continue for a significant amount of time

15. Role of Agencies • Identify children needing services • Identify services needed by the child and family • Coordinate services within agency • Coordinate services across agencies • Use a case manager, if needed

16. How to Access SOC/MAP • Refer through your agency representative to the MAP Team • Refer directly to the MAP Team leader • Refer through community mental health center

17. Demonstration Sites • 1999-2006, Children of Mississippi and their Parents Accessing Strength Based Services (COMPASS)in Hinds County • 2006-2012, the Pinebelt System of Care in Forrest, Lamar and Marion Counties

18. Acceptance of System of Care • Surgeon General’s Report, 2000 • Report of the President’s New Freedom Commission, 2003 • Over $100 million annual funding by Congress through the Center for Mental Health Services, SAMHSA • Lawsuit settlements in several states • State statutes and policies

19. Relevance to Children Exposed to Trauma • 20 years of study of system of care issues has clarified the value of context of services • Studies of clinical effectiveness of services for children exposed to trauma have evolved separately • These two paths are merging for improved services to children and families

20. Definitions Trauma • Physical Abuse and Neglect • Sexual Abuse • Traumatic Grief • Domestic Violence • Community and School Violence National Child Traumatic Stress Network, 2006

21. Definitions Trauma • Complex Trauma(multiple trauma) • Medical Trauma • Refugee and War Zone Trauma • Natural Disasters • Terrorism

22. Two Groups of Children • Group 1: Children exposed to trauma who exhibit symptoms requiring treatment; show the potential for PTSD (about 20%) • Group 2: Children exposed to trauma who will recover without treatment (about 80%)

23. Description of the Groups Both may show the same symptoms initially • Group 1: Symptoms increase; children do not recover with initial intervention • Group 2: Shows resilience, recovery

24. System of Care for Group 1 They meet the definition of serious or severe disturbance: • The disorder interferes with daily functioning (sleep, school, interactions, thinking) • It is projected to be long term, without treatment • Long-term effects without treatment can be damaging

25. SOC Principles Should Apply • Child centered, individualized • Strengths based • Family focused • Community based • Comprehensive; formal and informal • Culturally competent • Accountable/evidence based • Coordinated across agencies • Requires care management

26. Evidence Based Services for Group 1 • Include: • Cognitive Behavioral Therapy • Eye Movement Desensitization and Reprocessing (EMDR) • Trauma Focused Individual, Family and Group Treatment

27. Online Course in Trauma Focused CBT www.musc.edu/tfcbt

28. Importance of Trauma Practices in Systems of Care Children exposed to trauma • Had higher service costs • Used more high-end services, including: psychiatric hospitalization, residential treatment,and crisis intervention services at higher cost Yoe, Burns et al, 2004

29. Importance of Trauma Practices in Systems of Care • Used more Case Management services at higher cost; and • Used more outpatient-clinical and medication management services at higher cost

30. Importance of Trauma Practices in Systems of Care Groups were the same in service use and costs in • Substance Abuse Tx • Home-Based Family Services • Day Treatment • Community Support Services • Behavioral Health Pharmacy • In-Home Services

31. Group 2, Why Intervene? • To alleviate traumatic stress reactions • To provide comfort • To (possibly) prevent longer-term, more serious reactions • To identify those who need more intensive interventions

32. SOC Principles for Group 2 • Not child centered, not individualized • Strengths based • Family involved • Community based • Comprehensive, only informal services • Culturally competent • Accountable/evidence based • Coordinated across agencies • Does not require care management

33. Community Based • Interventions delivered in the child’s “community” • With peers • In school or other group setting • Involves child’s helpers-parents, teachers, shelter aides • Uses indigenous assistants

34. Strengths Based • Focuses on stabilization • Corrects misperceptions • Emphasizes maintaining psychological control--coping • Emphasizes support systems • Focuses on health and self-care

35. Family Focused • Parents involved in planning • Parents involved in learning how to cope • Parents involved in ongoing support of children

36. Impact of Trauma on Schools Events of past 16 years: • Desert Storm—the first war fought on television • Oklahoma City bombing—news coverage • School shootings • September 11, 2001 • Hurricane Katrina Marlene Wong, 2006

37. Crisis & Emergency Planfor SchoolsMental Health Component www.ed.gov/emergencyplan

38. Mitigation and Prevention • Identify possible disasters • Identify potential hazards/ barriers to a good response transportation routes factories/other highly populated areas

39. Preparation Develop an emergency response plan; consider emotional responses • Establish relationships with mental health professionals • Develop protocols for response • Train staff in psychological first aid • Establish back-up systems • Practice, practice, practice

40. Response • Assess level of exposure • Identify those most at risk • Provide support/first aid • Provide timely information/media messages • Identify those who need longer-term intervention and arrange it

41. Recovery • Address long-term needs through interventions using coping strategies • Address long-term needs through referral to community or in-school specialists • Plan for anniversaries

42. Actions for Schools • Recognize children are vulnerable to many kinds of trauma through direct or indirect exposure • Central point for community—50% of people involved with school

43. Ensure Internal Coordination • Establish who is in charge • Establish roles for each entity school safety personnel resource officers school counselors/psych./sw school health teachers

44. Group 2: Evidence Based Services/Promising Practices • Psychological First-Aid • Post Trauma Stress Management • Classroom-Based Interventions or Group Interventions National Center for PTSD, 2005, Macy, Behar, et al 2005, Macy, 2006

45. Trauma Response Teams Examples of Effective Programs • Center for Trauma Psychology • Community • Classroom • Community Policing Project (Yale) • Community Stress Prevention Centre (Israel)

46. Center for Trauma Psychology-Community • Intensively trained volunteers • Follow a clear protocol • Establish contacts in communities • Provide Psychological First Aid/Post Traumatic Stress Management Informal evidence of effectiveness

47. Center for Trauma Psychology--Classroom • Uses classroom based coping groups • Trains teachers • Involves parents • Used also by Save the Children Most evidence of effectiveness

48. Community Policing Project • Highly trained staff • Train police to handle child cases • Ride along with police • Provide team interventions—psychologists & police together Informal evidence of effectiveness

49. Community Stress Prevention Centre (Israel) • Trains child caregivers, parents, teachers, first responders • Provides back-up • Experienced in international relief Informal evidence of effectiveness—theory based

50. Resources at www.nctsnet.org For • Educators • General Public • Juvenile Justice Professionals • Media • Mental Health/Medical Professionals • Parents and Caregivers • Policy Makers